Sponsored By€¦ · revenue $2,000,000 new revenue for the group ... seconds and one baby-boomer turns 60 every 7 seconds (10,000 a day) ... Patient Flow Is Predictable: Classic

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Hospital-Wide Patient Flow: Cracking The Code Patient Flow Conference

KIRK JENSEN, MD, MBA, FACEP Chief Medical Officer - BestPractices, Inc. IHI Faculty Member (Past Chair - IHI Improving Flow Through Acute Care Settings Collaboratives) (Past Chair - IHI Operational and Clinical Improvement In The Emergency Department Collaboratives) Urgent Matters/RWJ Medical Director - The Studer Group

© Patient Flow Summit, 2013

Quality, Safety And Service Have Always Been Core Drivers Of Our Mission and Performance

Six dimensions of quality 1.  Safety 2.  Effectiveness 3.  Patient-centeredness 4.  Efficiency 5.  Timeliness 6.  Equity

Crossing the Quality Chasm: The IOM Health Care Quality Initiative

All six dimensions of quality may be compromised when patients experience long waits times to in the Emergency Department or in the Hospital

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•  Nearly half of the E.D.s in the U.S. report operating at or above capacity

•  9 out of 10 hospitals report boarding”patients in the E.D. while waiting for inpatient beds

•  Approximately 500,000 ambulances are diverted each year away from the closest hospital

Why Address Hospital Crowding?

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•  Several studies have presented clear evidence that crowding contributes to poor quality care

•  When capacity is exceeded errors are more likely to occur

E.D. and Hospital Crowding Compromises Quality

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0.902.74

4.16

012345

0-30 minutes

30-60 minutes

> 60 minutes

Time to Physician

Average Claims / 25k patient visits

A crowded E.D. increases risk – more than 4x the # of malpractices claims if longer than 60 minutes to see a physician versus under 30

minutes

Crowding Compromises Safety

Source: Studer Group and CEP

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Crowding Compromises Service Patient Satisfaction By Time Spent In E.D.

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© Patient Flow Summit, 2013 8


ACEP NEWS – January 14, 2013

• The Joint Commission says, “boarding in the E.D. requires a hospital-wide solution.”

• New performance standards put into effect Jan 1, 2013 require hospital leaders – namely the chief executive officer, medical staff and other senior hospital managers – to set specific goals to:

•  Improve patient flow

•  Ensure availability of patient beds

•  Maintain proper throughput in labs, O.R.s, inpatient units, telemetry, radiology and postanesthesia care units

The Joint Commission Targets Patient Flow

“We want to make sure that organizations are looking at patient flow hospital-wide, even if the manifestation of a flow problem seems to be in the emergency room.” ~ Lynne Bergero, The Joint Commission

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ER Patients Results 40,000 ED Visits x 1 Hr Reduction in LOS 40,000 Hours of ↑ED Capacity/

Year 40,000 Hours of ↑ED Capacity/ 2 Hours per ED Visit

20,000 potential new visits/year

20,000 new ED visits x $100/visit in physician revenue

$2,000,000 new revenue for the group

20,000 new ED visits @ $400/visit for the hospital $8,000,00 new revenue per year for the hospital

New hospital admissions at $3,00 - $7500 per admission

1 more admission per day (365) X $3,000-$7500/ patient admission =$1,095,00-2,737,500/year

*(AHRQ-only 6.2% of admissions through the ED are uninsured)

There is a Compelling Business Case for Flow- A Case Study

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The Business Case for Flow Continued…

Average $100 NCR MD income for every walkaway

Average $400 in hospital income for every walkaway

For a 50,000 visit ED= $50,000 in new MD revenue (no increased overhead) for every 1% reduction in LWBS/LWBTs A 1% reduction in walkaways = $200,000 in new outpatient hospital revenue

•  In 2007, 1.9 million people – representing 2% of all E.D. visits – left the E.D. before being seen (LWBS), typically because of long waits

•  These walk outs represent significant lost revenue for hospitals

•  A crowded E.D. limits the ability to accept referrals

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The Future is Now-The Baby Boomers are Here… Demographic growth is driven by the elderly: The 65 and older age cohort will experience a 28% growth in the next decade

•  One baby-boomer turns 50 every 18 seconds and one baby-boomer turns 60 every 7 seconds (10,000 a day)

•  This will continue for the next 18 years

This cohort will comprise 15% of the total population by 2016 A higher proportion of patients in this cohort, in comparison to other age groups, are triaged with an emergent condition One-quarter of Medicare beneficiaries have five or more chronic conditions, sees an average of 13 physicians per year, and fills 50 prescriptions per year…

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HARDWIRING FLOW


Hardwiring Patient Flow: Critical Patient Flow Concepts: Part 1

•  The front door and your front end processes drive flow

•  Triage is a process, not a place

•  Get the patient and the doctor together as quickly and efficiently as possible

•  “Fast track” is a verb, not a noun

•  Keep your vertical patients vertical and in motion

•  For horizontal patients, real estate matters; for vertical patients, speed matters

Kirk Jensen/Thom Mayer, Hardwiring Flow

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The Life Cycle Of A Patient Visit

Patient Flow And Patient Throughput Pushing AND Pulling Our Patients Through The ED And The Hospital

•  Door to triage •  Door to doctor •  Door to bed

Front end

•  Decision to admit/discharge

Middle

•  Discharge to home/admit

Back end

Pull Pull

Pull

Push Push

Push

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“Vertical” vs. “Horizontal” Patients

Vertical Patients •  Ambulatory •  Arrive by Triage •  Well •  Younger •  Perceived urgency or

convenience factor •  Value (Starbucks or

McDonalds) •  Speed •  Convenience •  Financial •  Other non-medical factors

Horizontal Patients •  Stretcher bound •  Ambulance Arrival •  Sick •  Older •  Perceived serious or life-

threatening condition •  Value (Traditional

Healthcare) •  Speed •  Safety •  Preservation of Life/

Limb

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Minimizing Door To Provider Time And Maintaining Forward Flow

Utilizing lean techniques, BestPractices operations models and process flow redesign

BEFORE AFTER

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1.   Keep area open, visible to all

2.   Keep patients upright

3.   Keep all equipment and manpower mobile

4.   Each station has to be user friendly

One Stop Shopping

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Lean Hospital Admissions at ThedaCare

“Encircle Health”

•  Anticipates and structures to meet all needs in one visit •  Lab designed to get results to patient record within 15 minutes •  Patients leave with one plan, all results

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Optimize Bed Capacity AND Utilization

Patients should be in a bed only if it is medically necessary

and only as long as medically necessary

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TABLE TURNS - How many times a table in a restaurant is used to serve a new customer

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Bed Turns-How Many Patients a Bed Can Serve per Unit of Time

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Fast Track Is A PROCESS, Not A PLACE

• Code Blue

• Code STEMI

• Code Stroke

• Code Sepsis

• Code Vascular

• Code …

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Demand-Capacity Management

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Patient Flow Is Predictable: Classic ED Patient Flow Curves

Emergency Department Admission Times : 1 Hour Increments

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[Trend-Star Data : Q-1 FY04 & 05

Number Of Pts

FY2004 Q-‐1 154 149 120 81 83 79 99 153 166 269 253 277 235 260 274 268 294 307 332 352 345 299 278 211

FY2005 Q-‐1 160 119 107 83 71 76 85 106 156 208 226 230 260 243 260 260 304 286 302 333 287 270 260 198

0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00

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Scientific Management- Matching Capacity To Demand: Arrivals Versus Staffing -Physicians

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Demand vs. Revised Capacity MajorCare - Heavy Days

Average Demand Modeled Demand Capacity

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Demand vs. Capacity MajorCare

Modeled Demand Average Demand Capacity

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Forecasting and Planning For Admissions

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Northwest Community Hospital E.D. Admissions

Admissions

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Hardwiring Patient Flow: Critical Patient Flow Concepts: Part 2

•  Be fast at fast things and slow at slow things •  The number one sign of the health of an E.D.,

O.R., PACU, ICU, or hospital floor is the relationship between the physicians and the nurses

•  Making people unhappy and then sending them a bill is not a healthy business model

•  If the boarding burden is not overwhelming, much can be accomplished by focusing on the front end and the throughput bottlenecks under your control and/or influence … think TOC and Lean …

•  If your boarding burden is overwhelming, you are….!@!&%#!

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ED Crowding And Boarders A major concern in E.D. patient flow is the number of admitted patients being held in the ED (boarders)

§  The greater the percentage of ED beds occupied by boarders (admit-holds) the more likely flow will be impeded or obstructed

§  Boarders occupy beds and consume resources that are staffed and allocated for incoming ED patients

§  There is an extensive body of literature on the negative impact of boarders in the ED (Bernstein SL. Et. Al. The effect of emergency department crowding on clinically oriented outcomes. AcadEmergMed.

16(1):1-10,2009 Jan.) There are a number of strategies that can help decrease ED boarding and accelerate movement into and through the hospital ED overcrowding correlates with the boarding of admitted patients more than any other metric

*ACEP Task Force Report on boarding

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ACCELERATING FLOW INTO YOUR HOSPITAL


Early Decision To Admit

•  In most cases, an experienced emergency physician or nurse will know if a patient needs hospital admission within minutes of entering the patient’s room and performing a brief assessment

•  Diagnostic testing is sometimes necessary to help select the type of bed needed (ICU, Progressive, Telemetry, Floor, Observation)

•  Delaying admission until every lab and diagnostic study is back is an unrealistic expectation on the part of the admitting team

•  In some hospitals, a culture change will be necessary to facilitate early admissions

•  Early consultation for admission is often resisted, despite the obvious improvement in patient flow

•  There are legitimate concerns about right patient, right bed, right service, right time •  It can be disruptive to the work flow of the admitting teams •  Saying “no” (or “not yet”) can smooth the workflow of the in-patient team

at the expense of the E.D. team

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Proper Bed Selection Have a written agreement and policy on bed selection; include key

factors such as telemetry, isolation, vasoactive drip, and others: •  The process goals are to add accuracy, reduce variation and improve cooperation in the

bed selection process •  The outcome goals are to efficiently and effectively place the patient in the proper

nursing unit (“best-fit”) and to facilitate the acceptance of the patient by that nursing unit (See Tools-“Bed Selection Criteria”)

Caveats: •  Admitting physician preferences will need to be taken into consideration as well •  The development of an optimal bed-selection process and tool is clearly the task of a

multidisciplinary team •  An agreement negotiated by diplomacy in a spirit of cooperation and mutual gain rather

than attempted in the heat of battle

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Express Admitting Units (EAUs) And ED Holding Areas •  Busy E.D.s need to decompress before the number of boarders starts to grow.

•  EAUs and Holding Areas are often geographically separate from the ED but usually located nearby.

•  The size of these units varies according to the number of ED admissions per day; usually from 5 to 15 beds (although some large EDs may have a 25 or 30 bed observation unit.)

•  Stable ED patients who require admissions are moved to a staging area (the EAU) using holding orders to await further evaluation and formal admission by the admitting team.

•  After evaluation, admitting service can select the most appropriate in-hospital bed. •  In some hospitals the EAU patients are the responsibility of the admitting team while the ED

Hold patients remain the responsibility of the ED team until the arrival of the admitting physician. •  EAU and ED Hold nurses must be relentless in

their pursuit of admitting orders from the in-patient team and fast-tracking the preliminary diagnostic and treatment plan.

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ICU Management •  ICU patients in the E.D. consume significant amounts of nursing

and physician resources and divert monitoring and care from other patients in the E.D.

•  There is also a correlation with the duration of time an ICU patient remains in the ED and subsequent mortality, especially for ED stays longer than 6 hours.

(Chalfin DB, et. Al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007; 35:1477-1483.)

Consider ICU “Fast-Tracking”

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ICU “Fast-Tracking” – One Example

POLICY • A Critical Care Alert can be called for patients meeting the following inclusion criteria:

•  Sepsis/Sepsis syndrome •  Acute respiratory failure requiring mechanical ventilation •  Resuscitation post-arrest •  Unstable hemodynamics requiring vasopressor intervention •  Intracranial hemorrhage with evolving neurological deficits or airway compromise

• Patients meeting inclusion criteria will have a Critical Care Alert called at the time they are recognized to meet inclusion criteria. • A 30 minute response time (from notification to arrival in ED) is required from patient’s physician or the intensivist. • Critical Care Unit will respond within 30 minutes of notification with both a bed assignment and a team for transporting the patient to Critical Care. • All immediate diagnostic radiology needs should be completed prior to transport. • The patient’s E.D. nurse will accompany the team to the Critical Care Unit to give bedside report.

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Adopt-A-Boarder Program •  Started independently at Inova Fairfax

Hospital and in Stonybrook, this practice has spread to many of the largest hospitals in the United States, including Duke, William Beaumont, and UCLA •  Admitted patients routinely spend hours

in the ED hallway while they await an inpatient bed

•  On a busy day an ED can have up to 10 patients at any one time in their hallway awaiting bed placement

•  Some patients wait 12 hours or more in the hall

•  Instead of having all 10 patients wait in a single hallway in the ED, what if we placed 1 patient each in 10 different hallways on inpatient wards? •  Would they get better care? •  Would they be more satisfied with their

boarding stay?

•  Admitted ED patients very much preferred the inpatient hallway to the ED hallway

•  Adopted boarders felt they got more personal attention and better care in the inpatient hallways than in the ED.

•  Nearly all patients stated that they were happy to be closer to their inpatient bed

•  Studies from Stonybrook, Inova hospitals, and UCLA showed that the Adopt-a-Boarder program accelerated bed turnover

•  Many patients who were destined for an inpatient hallway bed instead went straight to their inpatient rooms •  Beds were cleaned in a fraction of the usual time •  Patient satisfaction with the program was extremely

high at all hospitals studied •  Further discussion of this program can be found at

http://www.hospitalovercrowding.com/

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PARTNERING WITH YOUR HOSPITALISTS


From Door To Discharge

•  Seamless patient care from the emergency department (Door) to inpatient treatment and discharge

•  Two groups working together as ONE •  Improved admission process

•  Open communication

•  Less patient boarding

•  Shared goals

•  Better relationships

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Door-To-Discharge

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Teams And Teamwork: It’s About Your People

The A-Team

• Put your "A” team on the floor at all times!

• Hire right or repent at leisure – it’s your call

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Teams And Teamwork: It’s About Your People, Processes And Handoffs

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Teams And Teamwork: It’s About Your People, Processes And Handoffs

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DEMAND CAPACITY MANAGEMENT AND

INPATIENT SERVICES


A Bed Management Process

Admissions

Transfers

Discharges

Forecasting and Planning

Real Time Demand/Capacity System An Early Warning +

Response System

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An Administrative System For Flow

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Flow As A System

•  Many units/departments attempt to optimize patient flow •  Sub-optimizing flow in other

areas

•  Sub-optimizing flow throughout the entire acute care system

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This Is Not Your Typical Hospital-Wide Bed Meeting

Hospitals require an administrative system for flow that: ü  Predicts at a unit level the capacity to accept

admissions within a designated time period

ü  Predicts at a unit level the demand within a designated time period

ü  Documents a plan at a unit level if demand is predicted to be greater than capacity

ü  Evaluates the success or failure of predictions and plans

ü  Uses failures and successes of predictions and plans to develop the key improvement projects to improve flow

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FLOW, SURGERY AND

ANESTHESIA


What Makes Hospital Census Variable?

•  If E.D. cases are 50% of admissions … and …

•  Elective-scheduled O.R. cases are 30% of admissions, … then …

•  Which would you expect to be the largest source of census variability?

Eugene Litvak, PhD, Boston University

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The Answer Is … The E.D. and elective-scheduled O.R. have approximately equal effects on census variability. Why? Because of another (hidden) type of variability … Artificial Variability

•  Non-random

•  Non-predictable (driven by unknown individual priorities)

•  Should not be managed, must be identified and eliminated

Natural Variability

•  Clinical variability

•  Professional variability

•  Flow variability

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Smoothing Surgical Flow

•  The operating room has a significant impact on the flow of patients through the hospital

•  Smoothing surgical patient flow patterns leads to smaller ranges between high and low volume and opens capacity in both the O.R. and the inpatient areas of the hospital

•  Adjust the block schedule based not only on utilization but also on where the patient should go post-operatively

•  Fewer patients are placed off-service, which leads to a reduction in length of stay

•  An additional benefit is that placing patients in the appropriate bed and unit improves not only patient satisfaction but also physician satisfaction

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ORCHESTRATING THE DISCHARGE

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KEYS TO SUCCESS


Why Do Patient Flow Improvement Efforts Often Fail?

x The improvement projects are often not tied to the true bottlenecks in flow

x The changes resulting from the projects optimize flow at one stage (or unit) but do not optimize flow throughout the hospital

x Too few hospitals have the will or resources to sustain flow improvement efforts

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Key Principles •  Patient flow is a complex

technical problem

•  The Myth Of 100% Utilization

•  Patient flow cannot be solved by just one discipline or one department within the hospital

•  The solutions require high levels of cooperation and integration

•  Effective diagnosis of problems and effective testing of changes using PDSA cycles are required

•  The solutions cannot just be installed

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Facilitating Hospital Flow And Accelerating Admissions

•  There isn’t just one “silver bullet” … •  There is a portfolio of effective strategies –

a playbook, if you will

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Focus on Your Opportunities, Not Your Problems…

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The #1 Reason To Commit To This Is …

“It’s good for the patients … and it’s good for

the people who take care of those patients.”

~ THOM MAYER, MD

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RESOURCES, DATA, BENCHMARKING

AND REFERENCES

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Resources: Improving Patient Flow In The E.D.

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•  Why patient flow helps organizations maximize the “Three Es”: Efficiency, Effectiveness and Execution

•  How to implement a proven methodology for improving patient flow

•  Why it’s important to engage physicians in the flow process (and how to do so)

•  How to apply the principles of better patient flow to emergency departments, inpatient experiences and surgical processes

www.studergroup.com/hardwiringflow

Hardwiring Flow: Systems and Processes For Seamless Patient Care

Thom Mayer, MD, FACEP, FAAP Kirk Jensen, MD, MBA, FACEP

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The heart of the book focuses on the practical information and leadership techniques you can use to foster change and remove the barriers to smooth patient flow. You will learn how to: • Break down departmental silos and build a multidisciplinary patient flow team • Use metrics and benchmarking data to evaluate your organization and set goals • Create and implement a reward system to initiate and sustain good patient flow behaviors • Improve patient flow through the emergency department – the main point of entry into your organization The book also explores what healthcare institutions can learn from other service organizations including Disney, Ritz-Carlton and Starbucks. It discusses how to adapt successful demand management and customer service techniques to the healthcare environment.

Leadership For Smooth Patient Flow: Improved Outcomes, Improved Service, Improved Bottom Line

Kirk B. Jensen, MD, MBA, FACEP Thom A. Mayer, MD, FACEP, FAAP Shari J. Welch, MD, FACEP Carol Haraden, PhD, FACEP

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“This book marks a milestone in the ability to explain and explore flow as a central, improvable property of healthcare systems. The authors are masters of both theory and application, and they speak from real experiences bravely met.”

~ Donald M. Berwick, MD President and CEO

Institute for Healthcare Improvement

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Kirk Jensen, MD, MBA, FACEP Daniel G. Kirkpatrick, MHA, FACHE Table of contents Introduction: Why the E.D. Matters 1. A Design for Operational Excellence 2. Leadership 3. Fielding Your Best Team 4. Improving Patient Flow in the Emergency Department 5. Customer Service: Ensuring Patient Satisfaction 6. E.D. Change Initiatives: Getting Things Done 7. E.D. Change initiatives-Managing Change 8. Patient Safety and Risk Reduction 9. The Role and Necessity of the Dashboard 10. How the E.D. Is a Business 11. Billing, Coding, and Collections 12. Physician Compensation Models--Productivity-Based

Systems

The Hospital Executive’s Guide To Emergency Department Management

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Managing Patient Flow In Hospitals: Strategies and Solutions, Second Edition

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Real-Time Demand Capacity Management And Hospital-Wide Patient Flow

The Joint Commission Journal on Quality and Patient Safety: May 2011 Volume 37 Number 5

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The Improvement Guide and Rapid-Cycle Testing

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References •  Bazarian J. J., and S. M. Schneider, et al. “Do Admitted Patients Held in the Emergency

Department Impair Throughput of Treat and Release Patients?” Acad Emerg Med. 1996; 3(12): 1113-1118.

•  Building the Clockwork E.D.: Best Practices for Eliminating Bottlenecks and Delays in the E.D.. HWorks. An Advisory Board Company. Washington D.C. 2000.

•  Christensen, C, J Grossman, and J Hwang. The Innovator's Prescription: A Disruptive Solution for Health Care. 2009.

•  Fitzsimmons J., and M. Fitzsimmons. Service Management: Operations, Strategy, Information Technology. 5th ed. Boston: McGraw-Hill. 2006.

•  Full Capacity Protocol. www.viccellio.com/overcrowding.htm •  Goldratt, E. The Goal. Great Barrington, MA: North River Press, 1986. •  Holland, L., L. Smith, et al. 2005. “Reducing Laboratory Turnaround Time Outliers Can

Reduce Emergency Department Patient Length of Stay.” Am J Clin Pathol 125 (5): 672-674.

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References •  Husk, G., and D. Waxman. 2004. “Using Data from Hospital Information Systems to

Improve Emergency Department Care.” SAEM 11(11): 1237-1244. •  Jensen, Kirk. “Expert Consult: Interview with Kirk Jensen.” E.D. Overcrowding Solutions

Premier Issue. Overcrowdingsolutions.com. 2011. •  Kelley, M.A. “The Hospitalist: A New Medical Specialty.” Ann Intern Med. 1999;

130:373-375. •  Langley J, Moen R, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide. 2nd

Edition. San Francisco: Jossey-Bass 2009.

•  Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.IHI.org).

•  Wilson, M., and Nguyen, K. Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments. Urgent Matters White Paper. September, 2004.

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Benchmarking Resources Where To Find Data

• Your neighbors •  Call and/or visit

• ACEP •  http://www.acep.org

• Premier •  www.premier.com

• VHA •  www.vha.com

• E.D. Benchmarking Alliance •  www.edbenchmarking.org

• UHC •  www.uhc.org

Be sure to compare hospitals with similar acuity and similar volume …

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